Detecting and managing complications in cataract patients

In order to ensure good cataract outcomes with the minimum of complications, the following are all essential: • Well-trained staff • Excellent teamwork • Good pre-operative evaluation (including history taking, examination, investigations and biometry) • Infection control (including prophylaxis) • Functioning equipment • Sufficient consumables (including intraocular lenses) • Good postoperative care. Even if these are all in place, problems can arise with a patient who can't keep still in theatre, an eye that is deep-set and difficult to access, a small pupil, weak lens zonules (whether due to pseudo-exfoliation or subluxation) or a hyper-mature cataract that requires a high degree of surgical skill. If the posterior capsule is ruptured and there is vitreous loss, there is a higher risk of postoperative complications such as endophthalmitis, retinal detachment or macular oedema. Poor vision postop-eratively can be caused by uncorrected refractive error, particularly if no intraocular lens (IOL) was used or the wrong power IOL was inserted. Things can also go wrong in the postoperative period if postoperative complications are missed, or if periop-erative complications are not managed well. It is therefore important that all eye health workers who come into contact with the patient postoperatively know the basics of what the operation entails and what is normal so that they are alert to any signs or symptoms that might require action. They must know how to recognise an early or late complication and how to manage it effectively to prevent loss of sight – which we will cover in more detail in this article. Complications are rare and in most cases can be treated effectively. In a small proportion of cases, further surgery may be needed. Very rarely, some complications can result in blindness. Some complications may arise despite a good initial surgical outcome but in most settings they can be avoided through effective communication between the eye team and the patients. Good rapport is needed with an honest discussion about expectations right from the start. As a general rule, worsening sight, increasing pain, redness, swelling and discharge are all symptoms or signs that should trigger a referral. What follows is a list of complications and advice on how to manage them in order to minimise the risk of a poor outcome. These are complications which occur immediately following the operation (and may have their origin in the operation itself). With adequate vigilance and monitoring of patients postoperatively they can …


INTRODUCTION
In order to ensure good cataract outcomes with the minimum of complications, the following are all essential: Even if these are all in place, problems can arise with a patient who can't keep still in theatre, an eye that is deep-set and difficult to access, a small pupil, weak lens zonules (whether due to pseudo-exfoliation or subluxation) or a hyper-mature cataract that requires a high degree of surgical skill. If the posterior capsule is ruptured and there is vitreous loss, there is a higher risk of postoperative complications such as endophthalmitis, retinal detachment or macular oedema. Poor vision postoperatively can be caused by uncorrected refractive error, particularly if no intraocular lens (IOL) was used or the wrong power IOL was inserted.
Things can also go wrong in the postoperative period if postoperative complications are missed, or if perioperative complications are not managed well. It is therefore important that all eye health workers who come into contact with the patient postoperatively know the basics of what the operation entails and what is normal so that they are alert to any signs or symptoms that might require action. They must know how to recognise an early or late complication and how to manage it effectively to prevent loss of sight.

Ronald. World Journal of Pharmaceutical Research
Complications are rare and in most cases can be treated effectively. In a small proportion of cases, further surgery may be needed. Very rarely, some complications can result in blindness.
Some complications may arise despite a good initial surgical outcome but in most settings they can be avoided through effective communication between the eye team and the patients.
Good rapport is needed with an honest discussion about expectations right from the start.
As a general rule, worsening sight, increasing pain, redness, swelling and discharge are all symptoms or signs that should trigger a referral.
What follows is a list of complications and advice on how to manage them in order to minimise the risk of a poor outcome.

Early complications
These are complications which occur immediately following the operation (and may have their origin in the operation itself). With adequate vigilance and monitoring of patients postoperatively they can be detected and treated while the patient is still in the clinic. In addition, ensure that patients know they must alert a member of staff if:  They experience pain (rather than slight discomfort).
 If their vision is reduced in any way.
 If they notice any redness, swelling or discharge in their eyes.
Discomfort. Most patients will stay overnight before having their first dressing the next day.
Some mild irritation can be expected which usually settles down over 1-2 days and the eyesight gradually improves. Severe pain is unusual and may indicate raised pressure in the eye or the start of an infection. If the eyesight is improving and the eye not unduly red and the discomfort is mild, simply reassure the patient that it will get better.

Bruising or swelling of the eyelids/ sub-conjunctival haemorrhage may occur if a sub-
Tenon's or peri-bulbar local anaesthetic injection has been given. It may take a week or ten days to settle. The patient can be reassured. Intraocular haemorrhage (hyphaema) caused by a bleeding wound or iris is rare. If significant or the intra-ocular pressure is raised, medical or surgical intervention may be required. protocol should prevent the wrong IOL being implanted. Refraction will reveal whether the IOL power has been miscalculated. Spectacle correction would normally allow the patient to benefit from the operation.
Postoperative refractive error is confirmed using retinoscopy and corrected using spectacles.
This is usually done one month to six weeks postoperatively.

Infection in the eye (endophthalmitis)
is the most serious complication with an incidence that varies from less than 1 in a thousand to several times that figure depending on the criteria of diagnosis, and whether the cases are culture-proven or clinically diagnosed. When acute, it develops in 2-5 days with pain being a prominent symptom. However, endophthalmitics can present up to 6 weeks after surgery. Ciliary injection (redness around the cornea) and conjunctival chemosis occur, and pus in the eye (hypopyon) may be visible in the anterior chamber. Immediate referral for culture and intravitreal antibiotics may save the eye.

CONCLUSION
The end of the operation is the beginning of an anxious period for the patient, when they are hoping that their sight will be restored. If complications have occurred the patient must be kept informed and the outlook must be explained to them. Postoperative symptoms should be www.wjpr.net Vol 6, Issue 8, 2017. 892

Ronald. World Journal of Pharmaceutical Research
heeded and signs carefully looked for in case intervention is required. Good preoperative counselling and awareness of postoperative problems will help to ensure that complications are detected early and managed effectively.